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J Obstet Gynecol India Vol. 56, No. 2 : March/April 2006 Pg 113-114 EDITORIAL The Journal of Obstetrics and Gynecology of India Destructive operations in obstetrics Unduly prolonged obstructed labor with the fetus jammed in hemorrhage and one from severe postoperative shock after the pelvic cavity beyond any hope of spontaneous delivery is cesarean section. Six percent had vaginal lacerations and 3% not seen in the developed countries today. But such a situation urinary or wound infections. They state that their 0.094% is prevalent in the developing countries across the continents. incidence of obstructed labor was lower than 0.24 to 0.283% . It plagues thousands of women every year and accounts reported from other Indian hospitals. They found that women for 8% of maternal deaths in developing countries 1 . In India were referred late from the PHCs and emphasised the need 70% of our population lives in rural areas with barely any to train the PHC doctors in performing craniotomy, modern obstetric facilities. Antenatal care is mostly not decapitation and evisceration. In 2001 Biswas et al 3 from available or not availed of for various reasons. Home deliveries Kolkata, reported a 1.17% (141 in 12,034 deliveries over a with untrained female attendant is almost a norm. In India year) incidence of obstructed labor – 0.29% or 36 with dead 50% deliveries lack skilled or trained assistance. When labor fetus. 44.4% underwent craniotomy and 55% evisceration. gets obstructed due to contracted pelvic and fetal Cephalopelvic disproportion was the commonest cause of malformation or malpresentation the pauturient, as an obstruction. There was one traumatic rupture of the uterus inevitable last recourse, is taken to the nearest primary health but no maternal death. center (PHC) which is often quiet a distance away requiring time consuming arduous journey. The arriving parturient often In 2005 Singhal et al 4 , from a medical college hospital in merits the description of a woman in neglected obstructed Haryana, reported 51 destructive operations done for labor with a dead fetus and distressed mother with obstructed labor with dead fetus over a 7 year period. Of dehydration, advanced infection and a uterus desperately these 68.62% women had craniotomies, 19.60% had trying to surmount the obstruction. The PHCs, more often decapitation, 7.84% had evisceration and 3.92% had than naught, lack necessary skilled obstetric and anesthetic cleidotomy.Cephalopelvic disproportion was the commonest services, and adequate surgical and ancilliary facilities like indication. Two fetuses were groosly malformed, 49.05% blood transfusion to deal with the ordeal of the suffering weighed between 3 and 4 kg, and 9.43% were macrosomic. parturient who just needs a simple craniotomy or cleidotomy 49.09% women developed complications like atonic or a difficult decapitation or evisceration or a prompt cesarean postpartum hemorrhage, vaginal and perineal tears, puerperal section with all its morbidity. Unable to offer these life saving sepsis, and urinary infection. There was no maternal death. procedures the woman is sent on another ordeal of a long The authors rightly conclude that destructive operation is a and difficult journey, consuming very precious time, to reach good option even today. Adhikari et al 5 from a Medical College a tertiary health care center usually attached to a medical hospital in Kolkata report in 2005 a 0.56% incidence of college. Cesarean delivery is often resorted to as an easier obstructed labor (245/43906 deliveries) from January 1993 way out in preference to destructive operations, often for to December 1998. 63.27% or 155 were delivered by want of training and skill in conducting these rewarding cesarean section and 36.73% or 90 had destructive operations procedures. - 67 craniotomies (60 for cephalopelvic disproportion, four for hydrocephalus and three for arrested after coming head), Arora et al 2 from a medical college hospital Pondicherry 21 decapitations and two eviscerations. reported in 1999, 33 destructive operations performed between 1981 and 1991 – 27 craniotomies, two decapitations, Of the 94 (38.37%) women with dead fetus eight were three eviscerations and one cleidotomy. In three cases the delivered by cesarean section. In all 12 cesarean babies died procedure failed needing cesarean section. Indications for within 30 minutes of birth. Five mothers died after craniotomy were hydroceplalus (52%), obstructed labor craniotomy, not because of craniotomy but due to (19%), arrested after coming head (7%), cord prolapse (5%), complications of eclampsia. 7.09 (11/158) had complications persistent mentotransverse (4%), and placental abruption after cesarean rectus - wound infection, urinary infection, (4%). There were two maternal deaths one from postpartum and hematoma in the broad ligament or rectus sheath. 113 Editorial Amongest the 90 destructive operations there were two hospital to a PHC for 6-12 months. Incidently, this deputed vesicoaginal and two rectovaginal fistulas, and 15 genital person will also improve the overall obstetric skill of the PHC tears - a complication rate of 21.11% (19/90). The authors doctor and the obstetric services offered at the PHC. advocate an individualized approach to obstructed labor. References Gupta and Chitra 6 from a Medical College hospital in Delhi 1. Cron J. Lesson from the developing world : obstructed labor and the compared 56 destructive operations for women arriving late vesico-vaginal fistula. Ob/Gyn and Women’s Health. Medscape General in obstructed labor with a dead fetus done between 1985 and Medicine 003;50:2003. Medscape Posted 08/14/2003. 1991 with 27 cesarean sections done in 1989 and 1990 for 2. Arora R, Rajaram P, Oumachigui A et al. Destructive operations in similar indications. They found that destructive operations modern obstetrics in a developing country at tertiary level. Br J Obset had no maternal death, few complications, and short hospital Gynecol 1993;100:967-8. stay while cesarean section had one maternal death, long 3. Biswas A, Chakraborty PS, Das HS et al. Role of destructive operations hospital stay, need for blood transfusion, and more in modern day obstetrics. J Indian Med Assoc 2001;99:248-51. complications. They rightly concluded that destructive 4. Singhal SR. Chaudhary P, Sangwan K et al. Destructive operations in operations not only have a place in developing countries but modern obstetrics. Arch Gynecol Obstet 2005;273:107-9. when feasible are safer than cesarean deliveries. Reports 5. Adhikari S, Dasgupta M, Sanghmita M. Management of obstructed from Africa project a similar picture, quoting the incidence labor: a retrospective study. J Obstet Gynecol India 2005;55:48-51. of obstructed labor as 1.27% (207/16221) 7, 0.96% (380/ 6. Gupta U, Chitra R. Destructive operations still have a place in 39456) 8 and 4.7% (527/11299) 9. developing countries. Int J Gynaecol Obstet 1994;44:15-9. 7. Dafallah SE, Ambago J, El-Aguib F. Obstructed labor in a teaching Although obstructed labor in banished from the western world hospital in Sudan. Saudi Med J. 2003;24:1102-4. where the destructive operations are obsolete and not needed, in developing countries like India obstructed labor with dead 8. Konje JC, Obisesan KA, Ladipo OA,. Obstructed labor in Ibadan. Int J Gynaecol Obstet. 1992;39:17-21. fetus and severe infection is a sad reality, and destructive operations are an essential part of obstetric practice and 9. Ozumba BC, Uchegbu H. Incidence and management of obstructed cannot be wished away. In many situations they should be a labour in eastern Nigeria. Aust NZJ Obstet Gynecol 1991;31:213-6. preferred option to cesarean delivery which needs much better facilities and greater morbidity. There in a great need for training PHC doctors in performing destructive operations Mahendra N. Parikh and in judging situations where these are apt. This can best 43 Vasant , Off Carter Road be done by deputing a competent person from a teaching Khar, Mumbai 400 052 Tel. : 022-26001465 /26484052 Email: firstname.lastname@example.org 114
"Destructive operations in obstetrics"